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A Roadmap To Help You Choose The Best Nursing Home Facility For Your Elderly Family Member: What To Ask and What To Expect
Jan L. Warner & Jan Collins

UPDATE: Be sure to visit The Center For Medicaid & Medicare Services to search the government databases on facilities. To find an attorney to help you on the legal side visit National Association of Elderlaw Attorneys and to find a geriatric care manager to round out your team visit Care Manager.ORG.

Because our population is aging, many of us must deal with the difficult issues surrounding how to properly care for our parents and relatives when they are no longer able to live independently or when they require constant care.

Although home care may be an option in some instances, skilled or intermediate nursing home care may be the best way to deal with these difficult care questions. Before you take this step, however, you should understand how to evaluate which facility will be best for your family situation. No one can tell you which facility is the best, but, by taking the right steps, you can make an informed decision.


You may be short-changing yourself and your elderly relative by choosing the facility closest to you without doing any shopping. While some facilities are fine, others have histories of violating state standards and providing poor care. So seek recommendations from friends who have elderly relatives in nursing homes and from your doctor or nursing staff. Then it's a good idea to visit three to five facilities as close to you as possible and talk to the Director of Nursing or Administrator.


When you arrive at the facility, pay attention to the smell because if residents are not kept clean, the facility will smell bad. And if the floors are not clean, it means that the facility does not place cleanliness as a high priority.

Don't take what you are told by a facility employee as the gospel. When you visits the facilities in which you are interested, ask for the written policies of each and find out whether these policies are followed. Speak with both the administrator of the facility and the staff personnel who work with residents and family members. And learn what you can from other residents of those facilities and their families. Pay close attention so you can decide whether or not you are getting straight answers and whether the answers you are getting are consistent with what you see at the facility.


The state governmental agency that licenses nursing facilities can provide you with information about which facilities have been prosecuted for abuse or neglect of their residents, and the compliance history of a facility in which you may be interested.

Be sure to ask about the following over the past year or two as to each facility in which you are interested: The number of complaints filed and how many of those were found valid; the number of deficiencies cited; the number of quality of care violations cited; the last inspection by the state agency and the results; whether the facility's license had been terminated or suspended or threatened to be suspended; and the number of quality of car violations cited.

Since state agencies inspect each facility each year, you should get a copy of the last facility survey report and all follow-up reports which describe both violations and efforts by the facility to correct them. You will be well-advised to stay away from a facility if it is the subject of reports reflecting poor care, incompetent staff, poor managerial attitude, or delays in correcting violations,

Remember, facilities try to be at their best when inspection time rolls around. And remember also that since most facilities have some violations, you should be more concerned about some violations than others as some violations alone do not necessarily mean poor care. For example, there are standards in the areas of nursing care, quality of life, dietary services, physician services, rehabilitative services, infection control, pharmacy services, facility management, and observation of resident rights. Violations of these standards will be shown on the reports. Some of the areas covered are listed at the end of this file.


The law requires that a nursing facility employ a "sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident."

Most of the direct care which residents receive each day comes from aides who are supervised and supplemented by licensed nurses. These services include going to the bathroom, bathing, dressing, walking to the cafeteria, eating, and cleaning up when necessary. If there are not enough aides, residents will have to wait for attention and, many times, they get no help.

Even though no specific number of staff or ratio is required by law, the National Citizens Coalition for Nursing Home Reform has determined that the minimum ratio of direct care givers to residents over the three daily work shifts should be as follows:

Day Shift -- One direct care giver to five residents

Evening Shift -- One direct care giver to ten residents

Night Shift -- One direct care giver to 15 residents

So ask about the ratio of nurse aides to residents for each of the three daily shifts. Find out whether there is a facility policy about this ratio. A good policy will address quality of care issues while a bad policy will be vague or refer only to numerical standards without reference to quality of care. In addition, the facility policy should call for enough nurses and nurse aides to provide good care and prevent avoidable deterioration of each resident's health.

Important Note: When a facility tells you the average staffing numbers for the entire facility, it may be trying to hide the fact that less profitable units -- namely Medicaid -- are understaffed while more profitable units -- Medicare and private-pay -- are fully staffed.

And determine how often the facility uses temporary employees who may not be familiar with the residents or the facility. And when you ask, be sure make sure that the answer given deals with the number of aides -- or direct care givers -- who actually work, not the number who are scheduled to work because, especially in poor facilities, aides fail to show up for scheduled work shifts. In a good facility, there will be adequate staffing, and the facility will not use aides' failures to come to work as an excuse for not meeting minimum staffing ratios.

According to studies, the higher the levels of nursing staff, the better the care. By law, a nursing facility must have an RN on duty eight hours a day, seven days a week. In addition, a licensed nurse -- generally less trained and educated than an RN -- should serve as charge nurse on each shift. And the Director of Nursing should not double as a "charge nurse" -- that is, the nurse who is in charge during a shift -- unless a facility has less than 60 residents. Because of cost, a large percentage of nursing homes ask for, and receive, a waiver from these requirements.

If the facility won't tell you how many RN's work on each shift or tells you that RN services are not necessary or tells you that the facility complies with regulations, you may want to look for another facility, especially if "compliance" is accomplished through a waiver. In addition, if the facility uses temporary employees frequently in these positions, this should be a red flag that the facility does not pay enough to attract good nursing staff and relies on temporary employment agencies to fill in shortages. Again, stable, long-term staff members get to know residents and their individual needs can serve these residents much better than temporary staff.

And because staffing is so important, find out about turnover because this can effect the quality of care residents receive. Personnel costs are high, and when a facility is trying to strengthen its bottom line, it might try to cut staffing corners. There is nothing more important than competent, loyal, caring, long-term employees; however these types of people are unlikely to stay at a facility that requires difficult work loads, pays less than it should, offers few if any benefits, and offers no training.

If the number of nursing aides and nurses is too low, those who work are likely to be stressed, hurried, and not able to provide the type of care the residents need. High turnover equates to a lack of continuity of care which means that the residents will not know who are providing the care and the caregivers will not understand the resident's needs. Good staffing is essential.

Remember that nurse aides must be certified to take care of residents. Certification comes after completing a training program and demonstrating competence. So make sure to find out if the aides are certified because an untrained aide might not know how to avoid spreading infection from one resident to another, how to bathe a resident with delicate skin, or how to recognize when a resident needs emergency treatment. Although a nursing facility may hire uncertified aides and provide training, some facilities do this not only because their salaries lower, but also because some facilities charge them for the "training" they get while working.


Find out the number of complaints that have been filed against this facility in the past year and the nature of the complaints. And be sure to ask for the reports. Remember that unless there is an immediate threat to residents, most state agencies do not investigate immediately -- meaning that although a problem may have existed when the complaint was lodged, it may not exist -- or there may not be any evidence of the problem -- at the time of the investigation.

Find out if lawsuits were filed against this facility -- or its employees -- in the past two years? And if so, find out whether the suits were filed by the State or by private parties and what they were about and how they were disposed of. If a nursing home gets sued frequently, you should look for another facility -- especially if the lawsuits were based on improper nursing care. You may want to talk to the families who brought the suits.


Find out if there is an independent resident family council at the facility, and get the name and telephone number of the president. It is important to know that residents and their families have a right to meet with each other without the facility staff being present. By law, each facility must provide a private meeting place and must help residents attend the meetings.

At these meetings, problems and substandard care received by the residents are discussed. Because some facilities discourage these councils, interfere with meetings, fail to set aside meeting rooms, or retaliate against residents whose families are outspoken advocates, you should find out whether the facility you are considering encourages a family council and a resident council.


INCONTINENCE: Find out how the facility cares for residents who are incontinent, including the frequency with which residents are checked and cleaned up. If the facility has a written policy about incontinence, you need to see it.

A person may lose control of bowel and bladder functions in a nursing home, sometimes when the resident needs assistance to get to the bathroom and has to wait too long. Over time, the resident will become incontinent and must be kept clean and dry after each episode. Otherwise, the resident will suffer skin breakdowns from continued exposure to the waste. And once the skin breaks, the resident will be vulnerable to infections and further breakdown, especially when the skin is not kept clean and allowed to heal.

Unless the resident is unable to communicate, he or she will probably use a call bell or light to seek help. If the facility places high priority on responding to calls, residents are less likely to become incontinent. In good facilities, residents receive prompt assistance before or after an incontinent episode. You may want to stand by the nurses' station where call lights are and see how the staff responds when a light comes on.

CHEMICAL AND PHYSICAL RESTRAINTS: You should find out the number of residents who are physically or chemically restrained and whether each has a doctor's order. Read the facility's written policy about restraints.

By law, every resident has the right to be free from chemical or physical restraints unless necessary for his or her care. Although it might be easier for a facility to sedate residents or tie them to chairs than to provide adequate supervision for active, mobile, alert residents, discipline and convenience of the facility staff are not proper reasons to restrain residents. A good facility will use restraints only as a last resort.

Because physical restraints will cause loss of muscle tone, increased likelihood of falls, incontinence, pressure sores, depression, confusion, and mental deterioration, restrained residents should be checked and repositioned at least every two hours. Studies show that inappropriate use of restraints is often linked to short staffing. You can look around the facility and see if you can find residents who are either tied or strapped into chairs or who appear to be sedated with drugs. Ask why these patients are restrained.

PRESSURE SORES: Find out the number of residents with pressure sores, the number who developed these sores in the facility, and what the facility does to prevent and treat pressure sores.

Pressure sores -- called "decubitus" ulcers -- are one of the most serious problems faced by nursing home residents. Skin tends to break down when there is unrelieved pressure on a point which prevents circulation. Common areas are elbows, ankles, heels, and tailbones. These sores can penetrate through skin, tissue, and muscle-through to the bone. Pressure sores are usually an indicator of other serious deficiencies in the quality of care residents receive.

Skin also breaks down when it is exposed to urine or feces -- that is, when residents are incontinent and are allowed to lie in their waste.

Although a few pressure sores may be unavoidable, most can be prevented if residents who remain in bed are kept clean and dry, and turned at least every two hours. Residents with pressure sores are vulnerable to infection and have higher nutritional needs because healing requires more calories and protein. When residents have these sores, their dressings must be changed frequently by a nurse who has been trained not to spread infection. If the facility has a history of pressure sore problems, consider looking elsewhere.

EMERGENCY TREATMENT: It is important to make sure you ask about procedures for residents' emergency treatment, and if there are written facility policies, you should ask for a copy and read it. When a resident has a medical emergency, the nursing home should first, recognize the need for treatment and second, make sure the resident is sent to the hospital. If the nursing facility staff is not competent or is unfamiliar with a resident's medical history -- or if a resident's need is not noticed because staff are too busy elsewhere, a resident could suffer a medical emergency and receive no attention until it is too late.

Generally speaking, a nursing facility is not paid by Medicaid for the time during which a resident is in the hospital. Some facilities will allow a resident to suffer severe medical emergencies before calling an ambulance to send the resident to the hospital, while others require compliance with difficult administrative procedures before a resident can be sent to the hospital. If your family member has a medical emergency in the nursing home, you will want the staff to call the ambulance -- and you -- and not be trying to get authorization from a facility manager who is away from his desk or the facility.

PREVENTING ATROPHY AND RIGIDITY: Because it is important to keep people moving in order to prevent muscle atrophy and rigidity, you need to know the facility's policies and procedures.

Because people get very stiff if they do not move around, it is easy to understand why residents who do not move for several days will suffer from contracting and withering muscles. In a nursing facility, those confined to bed or wheelchair will lose range of motion. That's why they need passive exercise each day to help prevent this most avoidable deterioration.

Find out who in the facility is assigned to "range of motion" responsibility. Although not life threatening, this aspect of care has a big impact on quality of daily life.

ACTIVITIES FOR RESIDENTS: It is a good idea for you to find out how residents spend their time in the facility. Make it a point to find out whether there are planned activities that are both mentally and socially challenging.

Like all of us, nursing home residents like interesting activity. A good facility will plan daily events that include games, music, exercise, lectures, movies, local outings, shopping, crafts, and other activities in which residents having different levels of physical and mental ability can participate. In a poor facility, you will see residents watching television or playing cards or dominoes.

ARE MEDICAID AND OTHER RESIDENTS KEPT SEPARATE? Find out if the facility separates Medicaid and non-Medicaid residents and, if so, what is the difference in the treatment and level of service.

There is a better than even bet that if your family member enters a facility as a private pay resident, he or she will eventually become eligible for Medicaid. By law, a nursing home may not discriminate between Medicaid and non-Medicaid residents; however, differences may exist anyway. Find out if there is a "Medicaid section" of the facility; whether there is any difference in the food service, the staffing, the linens. Ask if parts of the facility are off limits to Medicaid residents and whether the staff knows which residents are Medicaid recipients. If they do, ask why they do.

RESIDENT TURNOVER: Find out the number of residents who have moved out of the facility in the last year and the number who were asked to leave and forced to leave.

Because entering or leaving a nursing home is difficult and traumatic, people don't generally leave one for another without a good reason. Although it is illegal for a nursing home to retaliate against any person for complaining about abuse or neglect, this happens. Poor facilities would rather get rid of "problem" residents than address the deficiencies which cause complaints to be filed. In these facilities, residents and their families may be intimidated and afraid to complain. Because this is hard to find out about, your gut reaction is generally your best indicator.

RESIDENT AUTONOMY: Find out whether the facility has substitute menu choices because some residents will not like the standard fare.

A very important consideration in choosing a facility is resident autonomy. Good nursing homes recognize individual tastes, and make it easy for a resident to choose from at least two nutritious meals while a poor facility will offer one meal and, for those who do not like it, the facility may serve cereal, toast and jelly or a "snack" that is not a balanced meal.


Physical, verbal, sexual, and mental abuse, involuntary seclusion; staff treatment of residents, proper investigation and reporting of abuse allegations.

Recognition of individuality and dignity.

Providing for residents' needs and individual preferences.

Housekeeping and maintenance for a sanitary, comfortable, orderly environment.

Clean bed and bath linens in good condition.

Assessment of each resident's needs to determine an appropriate, tailored care plan.

Comprehensive care plan for meeting a resident's medical, nursing, mental and social needs.

Quality of care so that each resident receives necessary care to attain the highest practicable well-being; prevent avoidable decline.

A resident's abilities in activities of daily living (bathing, toilet, eating, dressing, grooming, moving) should not be allowed to deteriorate unless this is clinically unavoidable.

A resident unable to carry out activities of daily living must receive help to maintain good nutrition, hygiene, and grooming.

A resident should not develop pressure sores unless they are clinically unavoidable, and a resident who does have pressure sores should get treatment to promote healing and prevent new sores.

Urinary incontinence; no catheters unless clinically necessary; infections should be prevented; normal bladder function in incontinent residents should be restored when possible.

Residents should be helped, with active or passive exercise, to maintain range of motion, to prevent decline of ability to move.

Residents should receive help with mental or social problems; residents who enter a facility without mental or social adjustment problems should not become angry, depressed, or withdrawn.

No nasogastric tubes to feed residents unless unavoidable; residents fed by tubes must not develop problems related to poor nasogastric care (ulcers, pneumonia, dehydration).

The facility must provide adequate help to prevent accidents and minimize accident hazards.

Adequate diet and hydration.

Residents' special medical needs must be met (injections, colostomy, prostheses, foot care, for example).

Residents must not be given unnecessary drugs .

Residents must not be subjected to significant medication errors.

The facility must provide sufficient staff to meet resident needs and maintain or attain the highest practicable physical, mental and social well-being.

There must be a registered nurse at the facility 8 hours a day, 7 days a week.

Food must be nutritious and palatable.

A facility must have an infection control program to prevent development and spread of disease.

Remember: The way in which inspections are handled varies from state to state. Always seek the assistance of professionals, including geriatric care managers, before you make final decisions.

Need more advice or help with this topic? Click here to get information about taking the "Next Step".
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